I am a plastic surgeon in Little Rock, AR. I used to "suture for a living", I continue "to live to sew". These days most of my sewing is piecing quilts. I love the patterns and interplay of the fabric color. I would like to explore writing about medical/surgical topics as well as sewing/quilting topics. I will do my best to make sure both are represented accurately as I share with both colleagues and the general public.

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Thursday, November 6, 2008

There seems to be a lot of interest in using fat grafts for breast augmentation these days. In the September issue of the Journal of Plastic and Reconstructive Surgery, there are two articles on fat grafting (only one of them to the breast per say). They are the first two reference articles listed below. I thought I would review them for you here.

The first one: Autologous Fat Grafts Harvested and Refined by the Coleman Technique: A Comparative Study

Background: The viability of fat grafts obtained by even a well-established technique remains poorly studied and unknown. This study was designed to determine the viability of fat grafts harvested and refined by the Coleman technique.

Methods: Sixteen adult white women were enrolled in this study. In group 1 (n = 8), fat grafts were harvested and processed with the Coleman technique by a single surgeon from the abdomen of each patient according to his standardized method. In group 2 (n = 8), fat grafts were harvested with the conventional liposuction by another surgeon. After centrifugation, the resulting middle layer of tissue was collected. All fat graft samples were analyzed for the following studies: trypan blue vital staining for viable adipocyte counts, glycerol-3-phophatase dehydrogenase assay, and routine histologic examination.

Autologous fat grafts have been used successfully for structural fat grafting in facial, lip, and hand rejuvenation and body contour improvement. Many believe that fat, as autologous tissue, can be considered the ideal soft-tissue filler because it is abundant, readily available, inexpensive, host compatible, and can be harvested easily and repeatedly. I agree with that.

The big If is whether fat grafts can truly survive after transplantation. This has always (and most likely will remain so) been one of the main concerns after fat grafting. The potential for a high rate of absorption over time in the grafted site can be up to 70 percent of the filled volume.

The most acceptable explanation for absorption has been based on the Peer's cell survival theory, which states that the number of viable adipocytes at the time of transplantation may correlate with ultimate fat graft survival volume.

So to improve the ultimate long-term result, the technique used to harvest the fatty tissue and to implant it must be such that there is maximum cell survival.

In 1994, Coleman first described his technique, which uses a syringe, cannula, and centrifuge, for structural fat grafting. He later refined and popularized his technique for fat graft harvesting and processing with the Coleman instruments and centrifuge and a centrifugation protocol, often referred to as the Coleman technique. By using his established technique for fat graft harvesting and processing along with his refined placement technique, many surgeons are able to achieve good long-term results with structural fat grafting.

This study compared the Coleman technique

Fat grafts were harvested and processed with the Coleman technique and spun at 3000 rpm for 3 minutes according to his protocol. After centrifugation, both upper and lower levels of components were removed and the remaining fat grafts within syringes were studied subsequently.

with traditional liposuction harvest

Fat grafts were harvested with conventional liposuction and spun at 500 rpm for 10 minutes. After centrifugation, the resulting middle layer of adipose aspirates was then studied for comparison.

Their result:

In this study, the total number of viable adipocytes was 4.11 ± 1.11 × 106 cells/ml in group 1 and 2.57 ± 0.56 × 106 cells/ml in group 2. The higher viable adipocyte count was found in group 1 compared with group 2. The difference of viable adipocyte counts between the two groups was found to be statistically significant (p < 0.004).

Glycerol-3-phophatase dehydrogenase assay was used in this study to assess cellular function of fat grafts in each group. The higher the enzyme activity level, the better the cellular function of adipocytes within fat grafts. The glycerol-3-phophatase dehydrogenase activity was 0.66 ± 0.09 U/ml in group 1 and 0.34 ± 0.13 U/ml in group 2. The higher level of the enzyme activity was found in group 1 compared with group 2. The difference of glycerol-3-phophatase dehydrogenase assay between the two groups was found to be significantly significant (p < 0.0001).

There was no evidence of fatty tissue degeneration or necrosis in either group. Normal structure of fragment fatty tissues was found primarily, and the basic structure of fragmental fatty tissues appeared to be maintained in both groups. No distinguishable differences were seen histologically in group 1 compared with group 2.

Even though its a small study, it looks like the Coleman method is superior than conventional liposuction for harvesting fat.

Second article: Fat for Breast: Where are We? (editorial) by Scott Spear, MD (only portions)

Autologous fat injection in general has achieved wide acceptance over the past decade or two. It is widely used by surgeons for face, buttock, hand, and postliposuction deformities. Its use in the breast has proceeded more slowly, perhaps for good reason. The breast can be augmented or reconstructed in most cases relatively easily with implants or flaps. It is important to remember that for reasons of disease detection, the breast is subjected to frequent radiologic and physical examinations, and greater than 10 percent of women eventually develop breast cancer. Thus, mimicking breast cancer, obscuring breast cancer, or causing breast cancer are issues that surround any breast procedure or device, particularly fat infiltration.

As we assess the value proposition of breast fat infiltration, we need to distinguish five different scenarios and assess them individually. Those five scenarios are:

As scientific investigations go, we are relatively early in looking into this subject. As we attempt to arrive at our conclusions, I suggest that we measure and examine five factors for each of these potential applications: efficacy, safety, cost, value/work, and liability.

It seems a strange thing for me to say, but maybe I’m too conservative to embrace this. Here are my concerns:

Fat necrosis (for example in breast reduction surgery or non-viable fat grafts) can cause changes in a mammogram that may make detection of breast cancer more difficult.

The time needed for the procedure. Breast augmentation with implants only take me an hour to perform. Breast augmentation with fat is estimated to take five or six hours.

Results at 6 months/12 months. With implants, the size will be the same at 6 months and at 12 months. Yes, revisions will be needed (see my post comparing saline to gel implants here). With fat grafts, take a look again at the first article -- “The potential for a high rate of absorption over time in the grafted site can be up to 70 percent of the filled volume.” What percentage of these women will need to be re-injected? And how many times will it need to be done? Will each revision take 3-5 hours?

The average surgeon's fee for implants is about $4,000 and for liposuction about $3,000, according to the American Society of Aesthetic Plastic Surgery. But breast augmentation with fat injections can cost about $20,000, Coleman says.

I have not even had good long term results with lip augmentation (we’re talking small volume of fat grafts needed), so why should I expect to have them with breast fat grafting? So for now, I’ll stick to what is predictable results for me. I will be watching the studies and techniques though.

One, led by Scott Spear, MD, chief of plastic surgery at Georgetown University Hospital in Washington, D.C., is seeking 20 women, aged 20 to 50, to undergo liposuction and fat grafting to augment their breasts.

Another, led by Roger Khouri, MD, a Miami plastic surgeon, will study augmentation with fat in combination with the use of the Brava system. The system includes semi-rigid domes worn over the breasts for several hours a day to induce breast tissue growth before the injections are done.

I have to agree with dragonfly. Anyone who wants my fat can have it.I don't get it anyway. I understand that some women need a boob job because of cancer .... But why are so many people having surgery just to correct "something".I really like your journal and I have learned a lot, so if I get on my soap box just tell me to shut up.Kelli

I don't know as it's ready to be used for breast reconstruction, but I'm also not qualified to say. I'm familiar with a case that used buttock adipose tissue to reconstruct from double mastectomies. While I understand her decision, to a point. I wonder if it would have been easier on her to go for implants. The decision was not mine to make, and I respect her for her determination and strong will. They have come a long way in reconstruction, but keeping that ever vigilant look out needs to be factored in, I would think. Anything that would obscure detection is a risk for each woman to weigh.

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